Monday, June 23, 2014

Frustrations Among Primary Care Physicians Should Be a Wakeup Call


Primary care physicians (PCPs) are incredibly frustrated. This level of frustration should be a wakeup call. The greatest frustration is “Time, time, time”- or more precisely, a lack of time. From in depth interviews with over 30 PCPs, everyone said lack of time was the greatest frustration of their practice (or was previously if they now were in a practice that limited the patient number to a manageable level.) Each knew that they could not give the time needed to give the level of care that they were capable of giving and that their patients deserved.
Stated somewhat differently, they said that it was very frustrating to always be focused on meeting overheads and trying to earn what they thought was a reasonable income because to do so meant less time with patients and a sense of frustration and perhaps even guilt. New practice patterns have meant not being readily available to patients, not visiting them at the hospital or ER, and no longer being the “captain of the ship.”
In a Daily Beast article, Dr D Drake wrote about “how being doctor became the most miserable profession….Simply put, being a doctor has become a miserable and humiliating undertaking. Indeed, many doctors feel that America has declared war on physicians—and both physicians and patients are the losers…It’s hard for anyone outside the profession to understand just how rotten the job has become—and what bad news that is for America’s health care system.”
The complexity of the healthcare delivery system was a common frustration refrain in my interviews. In such a fragmented system, “I need to go an extra mile to communicate with my patients but there is not enough time to do it.”
Other frustrations were dealing with insurers for preauthorization of a test, procedure or referral; trying to figure out what drugs were or were not on an individual insurer’s formulary (and each has a different formulary) and in dealing with their reimbursement methodology. Some insurers are very slow to pay reimbursements which mean carrying high working capital – difficult for a small practice.  One noted the amount of time required to arrange for something like home care which, if the insurer was logical, would actually prevent more expensive time in the ER, doctor’s office or nursing home. PCPs find it exceedingly frustrating to deal with non-medical people at the insurance company who deny tests or medications that the doctor feels are very much in the patient’s best interest.
So PCPs were frustrated by government and insurance regulations, polices and roadblocks to care; by the fragmentation of the system; and by many others things but the root problem that was most frustrating was the lack of time with each patient. 
Kevin Pho MD, a primary care physician and founder of KevinMD.com a very popular blog posted about physician frustration following Dr Drake’s article. “So it’s important to have the conversation on physician dissatisfaction.  It’s important to discuss the cost of medical education, physician burnout, and the myriad of paperwork and bureaucratic mandates that obstruct doctors from giving the best care they can to patients. Left unchecked, the physician profession will become completely demoralized.  Whether you care or not, it matters.   Demoralized doctors are in no position to care for patients.”
What is very clear in this extremely dysfunctional healthcare delivery system is that the primary care physicians  (and most other providers as well) are very frustrated that they cannot give the level of care that they believe they were trained to do  and would like to do. Most of their frustrations come down to the lack of time.
They need to take back the time and give it to patients, perhaps via direct primary care or with other models that offer a higher reimbursement for a patient visit or per member per month.  But medicine is a very conservative profession; change comes slowly. Doctors will make the switch to something better only if they feel comfortable that their patients will follow them and approve. Otherwise they will retire early or go work for the local hospital and medical students will continue to shun primary care as a career. If patients want to benefit from much better care, if they want a doctor that is not frustrated and can spend time with them listening, if they want their total costs of health care to decline rather than rise, then they will need to educate themselves and then to advocate  – to legislators, to insurers and to doctors. Concerted patient action will force the issue and make change occur. When the PCP has more time, care gets better, frustrations come down, satisfaction goes up and costs come way down. Everybody wins.
Next time: The value of integrative medicine in primary care.
 

Monday, June 2, 2014

What Are the Characteristics of a Good Primary Care Physician?


PCPs like people. This was true of them long before they started medical school and it will have only blossomed further during training. Ask PCPs, as I have with in-depth interviews, and they will tell you that certain types of individuals are drawn to primary care careers; they have common characteristics. They like to converse with people. They enjoy getting to know about a person – their ideals, their goals in life, their ambitions, their cares and sorrows. They are interested in learning from the patient rather than talking down to the patient; their ego can be strong but not as to impose themselves on the patient. They tend to not only want to know their patient but also to understand his or her place in their family and society. He or she is a person who wants to know the “whole story;” they tend to see the patient as a whole person, as part of a family and part of a community. They see the patient as a unique individual and his illness as part of that totality of the person, not just a diseased organ or system. To paraphrase Sir William Osler, a good doctor tends to the person who has a disease rather than just the disease itself.   
PCPs generally like to engage in an intellectual puzzle, a mystery to solve.  They have a “general contractor” mentality meaning that they see themselves as capable of getting much or even most of the job done themselves but are comfortable in drawing in others as necessary and in so doing are committed to coordinating everyone involved in the patient’s care. As with all of us, they wish to earn a good income but money is not the most important thing in their life nor is it what drove them to become physicians.
What are the characteristics of a good physician? The deputy dean for education at Yale Medical School, Richard Belitsky, M.D., talked to the freshman class a few years ago at their White Coat Ceremony about becoming a doctor. Greatly abbreviated, he told them there was much to learn “but so much of what you need to be really good doctors, you already know… Becoming a great doctor begins not with what you know, but who you are. Being someone’s doctor is about a relationship. That relationship is built on trust…Being a great doctor begins not with what you have to say, but your ability to listen.” 
In my interviews, primary care physicians report that listening is the key and most important attribute of being a good physician in primary care. By listening they mean one who listens to the patient’s story without rushing it and without embellishing it. They let the patient develop his or her own story of their situation perhaps with some prompts to help them focus but without unduly narrowing the narrative. The PCP must at the same time be nonjudgmental if he or she is to learn from the patient and develop a strong doctor patient relationship – the third major attribute.  PCPs need to like people and thus like their patients.  The good PCP is well grounded in basic medical science, the latest in evidence-based care and is constantly seeking continuing education. The good PCP is conservative, meaning that he or she will work with lifestyle, behaviors and other measures such as nutrition or exercise before resorting to drugs or procedures. This requires patience; not everything can be “fixed” immediately. They feel that knowing the patient over the long term aids the care process and enhances the doctor patient relationship as does being attuned no only to the physical needs but also the patient’s emotional and spiritual requirements. Knowing the patient’s family not only helps to understand the patient but they will be the physician’s ally if and when needed later. It is important to attend to the patient in the same manner that one would want to be treated by others. Combined, these will develop trust, respect and partnership. Some will not only be very good physicians but also true healers, a desired state that only some attain.
A physician who saw this post previously commented that I forgot two things – leaping tall buildings in a single bound and being a good typist. The problem of course is that PCPs today do not have enough time with their patients so even if they possess all or most of these characteristics they are trapped in a business model that does not value time.
When a general audience on LinkedIn was asked by Paula Stanziani what in one word constitutes a good doctor the answers varied of course but some of the most noted common attributes are these: Listener, commitment, compassion, humanity, attentive, patient, competent, teacher, healer and ethical. A good overview from one respondent, Scot Sturtevant, was “I’ve met many a physician in 36 years of service. Some brilliant, some not so much. The one thing I have noticed though those that were great, truly great, were those who were humble, but confident. They would listen quietly to a patient's story, and were never really rushed nor found themselves panicking in a critical situation. They were stoic yet responsive, and treated nurses, technicians and even field medics as a valued part of the team. To sum it they know who they are, and where they came from... And like all of us, still put their trousers on one leg at a time. There really isn’t a single word to describe greatness, it’s part of the diverse nature of who they are and how they apply what they've learned and what they know.”
That sums it up well for me.
Next post: The frustrations of being a primary care physician.
 

Praise for Dr Schimpff

The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.

-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).